# JACKSON PHYSICIAN CORP

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- **Entity:** Organization
- **Status:** Active
- **Other names:** BOONEVILLE MEDICAL CLINIC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1134261167
- **Authorized official:** LORETTA L CAMPBELL (CLINIC COORDINATOR)
- **Authorized official phone:** (606) 593-5395

## Contact information

- **Practice address:** HWY 11 SOUTH, BOONEVILLE, KY 41314-9621
- **Practice address phone:** (606) 693-0531
- **Practice address fax:** (606) 693-0535
- **Mailing address:** HWY 11 SOUTH, BOONEVILLE, KY 41317
- **Mailing address phone:** (606) 593-5395
- **Mailing address fax:** (606) 593-5444

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 02940 | KY | Yes |

## Other

- **Enumeration date:** 02/13/2007
- **Last updated:** 08/22/2020